By Jeni Miller
The physician advisor (PA) role has been evolving over the last couple of decades. Case managers are discovering their relationships with these clinicians can be incredibly valuable when made a priority.
“The role has changed because there’s such a need,” says Timothy Brundage, MD, CCDS, physician advisor and CEO of Brundage Group and co-chair of the CDI committee for the American College of Physician Advisors (ACPA). “Physicians are really taught the art of medicine, but a gap exists between the patient, the doctor, and the revenue cycle for the hospital. It all comes from the documentation from the doctor, and he cares for the patient in the hospital. There are different levels of engagement with the hospital, though, and what they document either will or won’t support the revenue cycle in the hospital.”
Since clinical specificity and coding are not same thing, a PA can act as a bridge between the two parties. “There is an increasing gap between the payor, the hospital, and the physician, and that’s something we even see in our media,” Brundage notes. “If you open up Becker’s [Hospital Review], it’ll tell you that payors are reporting billions of dollars of profit per quarter, but hospitals are really struggling. Hospitals need a bit of operating margin; they need to be in the black. They need to provide efficient and effective clinical care. A physician advisor helps the doctor be more efficient, and documentation can also support DRGs [diagnosis-related groups].”
PAs can play a role in preventing denials — something every case manager knows is a priority. “You almost can’t be a PA in this country without understanding that there’s a denials epidemic going on,” Brundage laments. “One out of seven claims are denied, so the PA is positioned to help both the provider and the hospital.”
Today’s PA helps with observation and inpatients, but also the timing of one compared to the other.
“That’s where the physician advisor starts — the utilization management [UM] function,” Brundage explains. “That naturally takes you to peer-to-peers, a verbal conversation between the PA and the medical director for the payor. The physician advisor is biased toward hospital, and the medical director is biased to the payor. We do 900 peer-to-peers per month at our company. While we don’t win them all, it’s a fair shake.”
During these peer-to-peers, the PA will talk with the medical director on the other side, a sort of back and forth on topics like whether the patient should be in the hospital due to medical necessity, how long they should stay, and whether it is appropriate for them to be moved to ambulatory outpatient care instead.
The PA also typically works on denial management, taking on tasks like authoring appeal letters. This is most helpful in medical necessity denial or DRG denial situations, or when the coder captured a diagnosis in error.
They also consult on contracts, helping the vice presidents of contracting or managed care in understanding the contract language and how to present it fairly to both parties.
Next, PAs are involved in quality metrics. “You have to start with quality care and then also provide quality documentation of that care,” Brundage says. “Some [clinicians] can provide quality care, but if the documentation doesn’t track well because they don’t know how to capture quality metrics, that can be a problem.”
A Valuable Relationship
The physician advisor/case manager relationship can be described as a liaison between the clinical team and the revenue cycle. While case managers typically are nurses, the PA is usually either a contracted or internal PA.
“They can speak to the director of medical staff and help with efficiency,” Brundage explains. “They work with case managers and ask questions like, ‘Do these tests need to be done in the hospital or can the patient transition to ambulatory?’ They are always working to be one step ahead of the payor medical director. They may determine in some cases that there is no medical necessity for the patient to stay in the hospital, and work with the case manager to get them out as soon as possible to avoid other risks of being in the hospital, like falls [or] bacteria.”
Like case managers, PAs are focused on moving patients to the next level of care, then supporting that transition. Often, they are involved in UM functions, working with the UM nurse to ensure criteria are met and the proper level of care is selected, especially in the case of complex patients.
Ease the Friction
Employing a PA can be a critical component that supports a healthy revenue cycle, ensures patients are receiving the proper level of care, and ensures compliance with Medicare Conditions of Participation.
“It’s of paramount importance to follow the Conditions of Participation to receive Medicare dollars, and we sometimes have to scrutinize for compliance,” Brundage says. “Physician advisors need to be educated and trained in this.”
One of the PA’s many roles is to ensure the hospital/payor relationship is as fair as possible. “Our hospitals are providing care to the community, but the payors are in the business of medicine,” Brundage says. “Hospitals are good at mission and vision, and payors are good at the bottom line. The PA can act as a liaison, helping with that relationship and making sure the payors work as effectively as possible with providers.”
One way physician advisors and case management leadership can do this is by paying close attention to “payor friction.” A document and diagram provided by Brundage Group described this payor friction. “Physicians are not taught how documentation translates to coding. All hospital revenue is determined directly from coding physician documentation, and coders can only code what is in the medical record. They cannot infer or assume, and can only query to obtain clarity from the physician, who is not incented to provide feedback. The payors are able to exasperate the documentation gap to reduce payments to hospitals. Payors implement policies and procedures that create significant process challenges for providers. These steps are presumed to ensure the patient has proper medical necessity, which is a reasonable request. However, opportunities for the process to fail are significant, thus creating ‘friction’ and causing delay. This revenue leakage exclusively benefits the payor. The payor wins by creating rules that are difficult to interpret while being the sole arbiter of provider compliance.”
The diagram Brundage shared showed what they call “common friction points” that lead to smaller reimbursements. Brundage says by knowing these friction points, PAs and case management leaders can help support a healthier revenue cycle for the hospital.
Working Together
Hospital case managers can best work together with PAs to promote positive outcomes, especially when there is frequent, bidirectional communication.
“There are so many opportunities to make sure that our team is engaged,” Brundage notes. “How many patients do we have in observation over 48 hours? That’s a number that hospitals should be scrutinizing since we should work all the time to minimize hours in observation. That’s a great metric to see how the processes are functioning, and you can find [problems] when you scrutinize like that.”
Measuring the Effect
It is important to use a hospital data analytics tool. Although it can be hard to track data effectively, it is necessary to show how a PA and their team can add value to the hospital and support the revenue cycle.
“To track this, it’s important to set the baseline before the physician advisor began, then watch the data afterward to see the impact,” Brundage says. “With the healthcare data options we have now, it’s so much easier to have a robust team to get data flow into the analytics tool to show impact and make hospitals more efficient.”
A good PA/case management team will clearly support the hospital’s effort in quality patient care, excellent documentation leading to higher reimbursement rates, and a healthier bottom line for the hospital.
The physician advisor role has been evolving over the last couple of decades. Case managers are discovering their relationships with these clinicians can be incredibly valuable when made a priority.
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